MEDICARE: MS. SUSAN E SMITH ATC LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1447289764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN E SMITH ATC LAT

Provider Business Mailing Address
First Line	:	1403 CARAQUET DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-2686
Country	:	US
Telephone Number	:	281-419-2218
Fax Number	:

Provider Business Practice Location Address
First Line	:	16713 ELLA BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-4213
Country	:	US
Telephone Number	:	281-586-1364
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	09/06/2023

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